How the Clinical Care Classification System Meets the Deedar-Ata Criteria - Essay Example

Clinical Care ification System Stephen Cerminaro, Michele Jackson, Cindy Nelson, Anita Westerheim, Kim Winne NUR 502: Theoretical Foundations ofNursing Practice Excelsior College Sabita Persaud December 5, 2014 HOW THE CLINICAL CARE CLASSIFICATION SYSTEM MEETS THE DESIDERATA CRITERIA Abstract Within the medical field, there are developments based on the new systems that are adopted in medical facilities. The need of vocabularies have been implemented to meet the expedite ventures of medical operations. Through the vocabularies are the technological advancements towards establishing concept that align to the achievement of better systems. The incorporation of electronic records on the formulation of vocabulary has since changed and revolutionized the nursing sector. The Clinical Care Classification has undergone several innovative changes within the 21st century. Through care, management programs are new systems that respond to the problems associated with the health sector. The mechanisms of the IMA and the Insight Plus have been implemented towards the establishment of better medical aid. Some failure and successes are evident through the undertakings. Medical informatics requires relevant vocabularies in order to support the best application within the existent medical standards. The medical informatics tends to describe the required standards to the international users and other personalities within the fields that utilize similar standards. The adoption process have been relatively slow given that for the past years since implementation, the system development has encountered difficulties attempting to meet the international scale needs. According to Cimino (1998), the looming question over the terms added to the vocabulary has been-‘why don’t it have what I want it to say?’ This correspondingly implies that the addition of more terms that meets the requirement of most people must be implemented for the system to work efficiently. Through implementing the list within the desiderata, there are possibilities of establishing controlled vocabularies sharable and reusable. Several aspects tend to hinder the task of listing the desiderata for the controlled vocabularies. Firstly, the desired characteristics of the vocabulary must be multipurpose in nature, and there are multiple intended purposes. The desired characteristics targeted by the listing range from: capturing clinical findings, the natural language processing, medical indexing records, indexing medical literature and representing medical knowledge (Cimmo, 1998). Aside from the above-mentioned problems in summarizing desiderata, differentiating opinions and putting them together is a major problem relative to the listings. According to Cimmo in his article ‘Desiderata for Controlled Medical Vocabularies in the twenty-First century’ Clinical care, Classification system has numerous features that are distinctive and tend to be specific to a terminology that meets the criteria for a controlled vocabulary. Within the CCC system, there are two concepts that focus on the terminologies. There is the CCC for nursing Diagnoses and Outcomes and the CCC of nursing Interventions/ Action . The two mentioned concepts are ‘granular’ or ‘atomic’ and their definitions ensure non-ambiguity and non-redundancy (Saba, 2012). The CCC system is context-free because the terms have stable concepts and distinctive codes identified. This ensures that the codes are never reused and are subject to only one time usage. There are three qualifiers in the CCC nursing and diagnoses that address both expected and actual outcomes. The system utilizes four qualifiers to identify the types of interventions/actions. These qualifiers include multiaxial, multihierachial and cominatorial (Saba, 2012). The CCC system has coded concepts within the structured framework, which are consistent, classified and functional electronic processing input and output. The framework can be implemented in several levels because it can be retrieved when the analysis is necessary or required. The coded data is essential as it is used for multiple purposes relative to the framework. The CCC system can document the nursing care process to provide the legal document of the patient care. The system supports clinical decision-making and captures data/concepts that can be retrieved, aggregated, and used for analysis and research” (Saba, 2012). The efficiency of the system establishes the four terminology criteria including concept orientation, concept permanence, non-ambiguity, and explicit version IDs. Concept orientation illustrates the coded concepts that are within their implied terminologies and have identical text representation. According to Saba, (2007), there are not redundant, ambiguous or vague concepts that exist within the coded framework. Concept Permanence explains that the significance of each coded concept as a terminology rests permanently. If there need arises to change the concepts, the coded concept is implemented successfully. Non-ambiguity implies that the within every concept is a clear terminology with a distinctive meaning. Similarly, the explicit versions IDs imply that every coded concept has uniqueness in identifying a varied selection. Further, there are other numerous criteria met by the CCC system ranging from the – no licensing fee, public domain and responsiveness to constituents. Care management program development resulted through analysis of Medicaid expenditures. This was implemented in line with reducing Medicaid expenditure and the improvement of client outcomes. The completion of the care management program is relative to the connection of primary care physicians and specialists. It will also link to the community resources and behavioral health treatment. Through the several implementation of the program, the accomplishment required includes the reduction of emergency room visits, psychiatric and medical hospitalizations. The care management RN tends to focus more on the medical aspect of the patient continuum and assist the care managers in making appropriate referrals to specialists. Evaluation Practice The care management program utilizes an electronic record-record progress notes, assessments and care plans. According to the article by Englebright et al (2014), rapid technological changes such as implementation s of electronic health records add to the complex milieu faced by nurses in the modern medical setting (Englebright et al, 2014). Additionally, Englebright et al agree that the electronic health records offer the potential efficiency in interdisciplinary collaborations due to the clear and concise documentation that can be deciphered among the patients, the treatment team and their families. Englebright, et al study was purposed in creating the definition of basic nursing care using clinical care classification that incorporates the electronic health records. On the findings of the research conducted, the result postulated that the basic nursing care included four action types of the CCC taxonomy. These four action types include assess and monitor, perform and provide and teach and manage (Englebright et al, 2014.) Organizations within our immediate region use two databases. Our own database uses the IMA and the insight plus. The IMA is the agency’s electronic health record where as Insight Plus is a Home does electronic health record mechanism. The IMA is utilized within the agency in almost every program within the medical facility including the clinic. The IMA facilitates implementing practices such as viewing the upcoming appointments and progress notes from other programs. IMA similarly exhibits its usefulness in establishing the inputs of the treatment plans. The system primary purpose is for billing. In conjunction with the Insight Plus, it has the ability to access the treatment notes and avail them to the caregivers including the therapists and doctors. Without the treatment plan, our facilities would meet extreme challenges in client billing services. The IMA treatment plan must be updated after every 6 months, the plan has been tailored to include more nursing goals and objectives such increased medication adherence and the follow up with the nutritionists/specialists. Within our agency, the utility of the Insight Plus as the primary care management platform was initiated in June. The care management using the Insight Plus mechanism has realized a number of successes and failures. A good example of the care management failures is relative to the attempt of merging of the client demographic information such as the date of birth and address. The process conduction was not smooth and we were forced to input most of the information manually. However, the treatment plan is much easier to fill out because during the work, the goals are added to the plan checklist. The system is more preferential to me as there is more room to identify the goals and objectives. Through the system, it is much easier to implement certain goals including the adherence to smoking cessation and nutritional plans. This enables the proper incorporation of the treatment team including the primary care givers and specialists, which implies an upper hand for the nurses since a concise treatment team is engaged. The system is utilized in the incorporation of the above-mentioned elements but not capable of billing until January when it might be required. Both of the systems have the positive and the negative aspects. However, currently, the combination of the two mechanisms avails the required aid. The systems respond using similar languages that allow the goals, objectives and progress notes to be written in CCC terminology. Some of the terminologies written include: ‘manage symptoms of diabetes’ , ‘manage specialists appointments’, ‘teach client deep breathing exercises’ and ‘provide contact information for care providers’. Strategic Action Plan Just like with any other process change, stakeholders form a vital part. The stakeholders’ incorporation within the process change is recruited, educated and geared towards the support of the change. The standardized Nursing Language facilitates the impetus recruitment and education of the parties that undertake the change process. The recruitment of leadership should be effected at an earlier stage in order to implement the process. The leaders too require education on the SNL, this allows them to appreciate the standardized terminologies and similarly identify the data of a specific patient and the care provided. The utility of SNL is efficient especially in demonstrating the outcomes, the workload and identifying necessary resources needed by the patient or general population on the costs of care. Proper utility of the SNL allows the abstraction of data for external reporting and quality improvement processes. Convincing the leaders on the need for accomplishment is important in order to generate support on the resources and the necessities required for implementation. The support is efficient and necessitates the implementation of the standardized nursing language at greater levels. Similarly, nurses also require recruitment and education on the benefits of documentation and use of the standardized nursing language. In the report ‘Principles for Nursing Documentation’, the American Nurses Association reiterates that the standardized terminologies permit data to be aggregated and analyzed. The terminologies therefore are inclusive of terms that used in describing the planning, evaluation and delivery of the nursing care and settings (ANA, 2010). Undertaking training and practice of any system require additional time. The ultimate time saving aspect of the standardized language persuades nurses on the ability to demonstrate contributions to the patient care and decisional support. Waddell et al (2011) postulate that an effective strategy that should be employed. This should include employees towards the planning and the implementation of the change process. This facilitates the circulation of ideas and relevant information. There is more chances and likelihood of accounting for the employees’ interests and worries are accounted for thus increasing the motivation to implement the change process (Christensen, 2014). Therefore, the incorporation of leadership in participation of the SNL is important as it expedites the change process. The incorporation of information technologists within the process is necessary as it facilitates the implementation of the SNL within the existent computerized health records. The necessary information on nursing should be provided to in order to establish the necessary information on the health care records and retention of the subsequent employees. It is important to indulge a quality and improved staff to enable the easy extraction of data. Standardization of documentation in populations provides the volume of evidence for the demonstration of nursing care. This provides easier data extraction for the external report and avails evidence for change where necessary. In corporation of quality assurers is important as they act as the instigators of leadership recruitment and the SNL nursing documentation. The development of the interdisciplinary methods can also be incorporated in order to allow the stakeholders have an input and participation within the change process. The incorporation of the interdisciplinary methods promotes the implementation at higher levels. The demonstration of support by leadership the interdisciplinary is required to meet and choose methods of implementing the SNL on a platform that is reflective on the nursing care and input. It is easily abstracted. Through the SNL incorporation, the electronic health record system has evolved into a continuous entity. Therefore, stakeholders should participate in the ongoing basis in order to enable the whole process to transpire with due urgency. Classification and Information Technology The need of information and practice on decision development of the interdisciplinary health care tends to drive the need of nursing diagnosis and classification systems in the medical setting. This is derivative based on the advent of computer-based application systems and method for control. The controls that are implemented within the classification system are majorly need-based and outcome driven in nature. The needs of the patients within a population derive the building blocks that are established towards the medical, technological and nursing classification system among others. Implementing the controls within the classification system requires the incorporation of leadership and research utility to be effected. Multiple research assessments on similar applications have been carried out in the past and one such method that is currently in use is the Health IT Usability Evaluation Model (Health-ITUEM). The ( Health-ITUEM) is an evidence –based program that draws its concepts, constructs and items form widely used and tested usability frameworks (Brown, et al 2013). When used as a framework in the basic sense of application methodology, this system works well. However, it does not prove to be an end-all in assessment frameworks. Methods to implement the practice decisions of application on these programs is reliant on the basic data similar to the written entries, copied, applied protocols or reprinted policies made into checklists or diagnostic classifications. Under the reimbursement concept, the utilization of pre-built diagnostic system refers the writer to implement standards of application that may or may not fit the current need of the patient’s treatment regimen. Following the basic care plans is important as it drive the team members through certain outcome-based regimen. The formulation that are required and similarly comprise of combined diagnosis and varying degrees of terminologies may fail to fit within such need as billing practices. The best example of such scenario is establishing the differences in the ICD-9 codes of encephalopathy. The diagnostic codes for treatment and billing purposes may fall under areas such as a psychological result (dementia) or a metabolic result (hypernatremia). This verifies that the adoption of a generic terminology platform is not always correct as presumed. Additionally, the assigned treatment plan, cost of utilization, and reimbursements vary depending on the service relative to the patient. This is evident in such a case as the physical versus speech rehabilitation. The further purpose and clarification of the acquired IT health system solidifies through the leadership guidance. Therefore, leaders must always acknowledge the needs for structured data representation. The goal-based outcomes and training in-services assist clarification of the standards. However, it is important to leave an idea open-minded in order to increase the formulation of practical-based change. This ensures that the systems, ideas and theories develop into manageable aspects of the patient care. Although the classification and terminology evolve, the need to verify all data sources is important. The verification should establish that the data sources are up to date, usable and classified accordingly. The understandable must be established through disciplinary service. In the nursing sector, it is evident that more research work and documentation is required in order to realize progress along the technological continuum. Conclusion In the nursing sector, it is evident that there are innovations established in order to enable efficiency within the medical facilities and care giving. To improve on these innovations the terminologies that are accepted and standardized according to the nursing practice is implemented. Through evaluation of the medical settings and establishing the classification incorporated with the information technology, there are good chances of implementing changes within the nursing record system. The introduction of the SNL requires corporation from both leadership and employee level in order to implement. The available systems are still open to change and can be improved by establishing better ways than the existent one. References American Nurses Association. (2010). Principles for nursing documentation: Guidance for registered nurses. Silver Spring, MD: American Nurses Association Publishing. Brown, W., Yen, P., Rojas, M., & Schnall, R. (2013). Assessment of the Health IT Usability Evaluation Model (Health-ITUEM) for evaluating mobile health (mHealth) technology. Journal of Biomedical Informatics, 46(6), 1080-1087. doi:10.1016/j.jbi.2013.08.001 Christensen, M. (2014). Communication as a strategic tool in change processes. International Journal of Business Communication, 51(4), 359–385. Cimino, J. J. (1998). Desiderata for Controlled Medical Vocabularies in the Twenty-First Cent ry. Methods of Information in Medicine, 37(4-5), 394–403. Waddell, D., Cummings, T., & Worley, C. (2011). Organizational change: Development & tranformation. South Melbourne, Australia: Cengage Learning. Englebright, J., Aldrich, K., & Taylor, C. R. (2014). Defining and Incorporating Basic Nursing Care Actions Into the Electronic Health Record. Journal Of Nursing Scholarship 46(1)50-57. doi:10.1111/jnu.12057 Saba, V. (2007). Clinical care classification (CCC) system manual: A guide to nursing documentation. New York: Springer Pub Co. Saba, V. (2012). Clinical care classification (CCC) system, version 2.5: User’s guide. New York. Springer Pub Co. Read More